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Claim by William DavidMasterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL M F MORA1\ DUM To: Mayor Roy D. Buol and Members of the City Council DATE: December 26, 2013 RE: Claim Against the City of Dubuque by William David Claimant Date of Claim Date of Loss Nature of Claim William David 12/23/13 12/03/13 Personal Injury This is a claim in which claimant alleges that he stepped onto an uneven curb on 26th Street, causing him to fall onto a sewer grate and injure himself. This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager Gus Psihoyos, City Engineer William David OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944 TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. The claim must be filed with the City Clerk at City Hall, 50 West 13th St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorney's Office. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to make any representation to you as to whether your claim will or will not be paid. 1 . Name of Claimant: i I 1\ CC m , 2. Address: a 5/ co Li n C,o i n /C blAb i 1.5-200t 3. Telephone Number 3° 4,;"2 75 f� 4. Date of Incident: 5. Time of Incident: j.)-/3/ l3 C6' :1-71-5 6. Location of Incident (Be specific): .ALY-t'n S1 no.1 -it am (A/K/19 ©h ",fir Salto ,�/i-eef a-(/YU 5s o1 1 'heir Lod bit 4- cle/�hn�6 r)/e /7(4r cewerJnr�-,� 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.) a/ _ 5 piled i-te on GCne-ver) 5 //epe.d fr. ntus�lty _Mc- -Iv fia! l ( h't y h e e/ /rl ff r n�q // se& k ef- a, v. - /� rea, rn.1` f� u ke d ( o{F cJ Less or .br,,da d -1"ne Ineven Jar-6 eaJaii�. 8. What were weather conditions like? 9. Give name and address of any witnesses: Roh�� Arkt(c5 /hp/0 7e e O-r A /auer /14-75,. 0/2 ,„?. ' 5f. 10. Did police investigate? (If so, give names of officers.) 165 /11&714(7/ /Vt vcrs 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Ju.si me- — Brow h ce-1 o ( o-F 12� �oo ✓— 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) A/O 13. What other damages do you claim, if any? Nh 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount id.) a 15. What amount do you claim from the City of Dubuque? lied Ica l bills, 71 /twP o Cr wo K mCornei pair, /Sa-G/A e/noSonal ess. 16. Why do you claim the City of Dubuque is responsible? G(neV/en Gu`bi;iq c 7dealaJ/ -K - /)3t ✓ /7 / e, Ca- us /riy * /0si h s /a it 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated this ,71-0 day of /LG��rvae4/ , 20 /3 (Signature) < jpa, /1d- (Print Name) Cil CO rn 0 !-n rn 0